National Health Service History
RHB(48)1 is amongst the most important early planning documents in the NHS, issued in January 1948 - in other words before the NHS began.. It is also probably one of the rarest. The author has a copy and has scanned and attempted to correct the errors thrown up by scanning a faded typescript reproduced on poor paper. Not all of it yet appears here.
The Ministry reproduced it in 1950 with minor revisions, including more paragraphs, and in normal printed format. Some reflected that time had moved on, and the RHBs were up and running. The title was changed to The Development of Consultant Services, and it sold for ninepence. A number of appendices and maps were added. Reading the guide today, the word "he" for doctors shows how few women were in the profession.
The Development of Specialist Services
1. In earlier memoranda sent to Regional Hospital Boards an outline has been given of their responsibilities and suggestions have been made as to the steps to be taken in setting up the new administrative framework for the hospital service and in preparing to undertake the immediate tasks which will face the Boards and Management Committees from the appointed day. The object of the present memorandum is different. It has been prepared, in fulfilment of the promise given in paragraph 24. of R.H.B.(47)1) in order to assist the Boards in facing the long-term problems arising in connection with the planning and future development of the specialist services.
2. It is clear that the first care of the Boards must be to ensure the effective maintenance of the present services. This immediate duty will be more satisfactorily discharged if it is seen against the background of the long-term organisation of the service. The attempt has therefore been made in this memorandum to examine the scope and content of the different specialist services; to consider how they might best be organised on a regional basis, bearing in mind the part to be played by the Teaching Hospital; and to estimate in terms of hospital facilities and medical staff what are the optimum future requirements of a developed service. In short, the aim has been to state objectives and to suggest methods by which over a period of years those objectives may be reached from the starting point of the existing resources in buildings and personnel.
3. Two points in particular should be mentioned. The first is that the memorandum is not put forward in any sense as a series of instructions which Regional Boards must follow. It seeks merely to suggest tentative answers to questions which each Board must necessarily face in considering the planning of the services for their area. The second point is the obvious one that the whole of the proposals made in the memorandum cannot be made effective on the appointed day. Arrangements must clearly be made for the continuance of specialist services from that day, based on the existing hospitals and on the part-time and whole-time specialists then available. Further suggestions will be made to Boards in a later memorandum as to the action needed to make these arrangements.
1. Historical. The planning of specialist services on a regional basis has been advocated in medical circles for many years. It has not hitherto been practicable, however, except in such limited fields as radiotherapy, and then only in a few-regions, where progress is of recent date. The distribution of specialists has been haphazard, determined in large measure by those economic factors upon which depends the existence of private consulting practice. There have been salaried part-time or whole-time specialist posts in general hospitals but they have been relatively few. Furthermore the tuberculosis service and the larger infectious diseases hospitals have been staffed almost entirely by whole-time salaried officers. But In the main specialist practice has been a matter of unpaid hospital responsibilities, coupled with private consultant work which has provided the whole or greater part of the specialist's income. The inevitable consequence has been an uneven distribution of specialists who are too few to meet the needs of the whole population.
2. Increase and Distribution of Specialist Staff. An immediate result of the introduction of the National Health Service will be the remuneration of specialists for all their work within the Service, unless they elect to serve in an honorary capacity. Thus, for the first time, there will be generally available the means of providing additional staff where it is most needed. Regional planning then becomes possible and will be one of the most important functions of the Board. Distribution can be improved by the creation of new salaried posts, part or whole-time, beginning first in those areas where the need is greatest. The deficiency in numbers can be made good only gradually because the training of specialists is necessarily long. Regional Boards should ensure, however, that only specialists of a high degree of competence are appointed to posts of responsibility. The mere possession of a special diploma is not the moat important qualification far specialist rank; adequate training and experience are better criteria.
3. Estimation of Numbers of Specialists. Subsequent sections of this memorandum will deal with individual specialties in detail and some attempt is made to forecast probable requirements in specialist services for a population of a given size. Such estimates must be largely speculative, as there is not yet sufficient information on which to base even approximately accurate estimates. But a plan of development, however tentative, is needed now, and it is the object of this memorandum to provide material which may be useful to Regional Boards in formulating their ideas. The realisation of those ideas may not be achieved for several years, since buildings on the scale required will not exist for some time yet, and the necessary specialists cannot be mass produced. It is imperative to avoid the mistake of expanding specialist staffs toe rapidly by recruiting men and women with inadequate training and experience,
4. Estimates of numbers of specialists given in subsequent sections are in the main, in terms of whole or half-time service at one hospital centre, but the proportion of the individual specialist's time given to the hospital service which may include domiciliary work) will vary. Some specialists may wish to engage whole-time in the service; others may engage in private practice for part of their time. Specialists employed part-time in one hospital centre may give part-time service in another associated centre.
5. Background of General Plan. The planning of the specialist services is one of the primary duties of the Regional Hospital Boards, but it is a task which must clearly be carried out in close collaboration with the Teaching Hospitals. Each of the 14 Regional Boards will normally provide a complete range of specialist medical service within its region. There is no wish to standardise specialist services throughout the country and each region will be able to plan these services in the way best suited to the local organisations and local needs; indeed experiment and variation between regions are essential to future development. There are, however, general principles which will be applicable in all regions and it is probable that broadly similar plans will emerge in each. The present memorandum has been prepared to give Regional Boards a general background which may be useful in the preparation of local plans. It is not intended to prescribe a pattern which must be followed or which can immediately be adopted in full, but merely to offer suggestions as to the broad lines along which development might be guided.
6. Distribution of Hospital Accommodation. The regions vary considerably in area, in population and in transport facilities; the smallest has a population of nearly one and a half millions and the largest one of over four millions. It is obviously impossible to provide all the hospital services required, for such large areas and populations in one Regional Centre itself; there must be Hospital Centres distributed throughout the region, each serving an area though shape and size of which is determined by density of population and also by Transport facilities. The region is, therefore, a composite group of hospital areas, dependent to some extent on a Regional Centre and on one another. Sometimes a Hospital Centre in one region will make use of specialist staff from a larger centre in another region or of special services provided at that centre. Each Hospital Centre should provide most kinds of specialist service and even the smallest will require a locally resident physician, surgeon, obstetrician and anaesthetist. The larger centres will naturally have a more comprehensive range of specialists resident in them and the smaller should be served by visiting specialists in those branches which provide insufficient work for a locally resident man.
7. Staffing of General Hospitals by Specialists. A common feature of the published reports of the Surveys of Hospital Services, undertaken during the war by the Minister and the Nuffield Trust, was the recommendation that the clinical responsibility for hospital patients, other than, those in general practitioner or cottage hospitals, should rest with specialists. It is necessary, therefore, to provide not only a sufficient number but a sufficient range of specialists. It is not enough to provide a general surgeon at a Hospital Centre and expect him to accept responsibility for all types of surgical cases. Ophthalmic surgery and the surgery of the ear, nose and throat, to take two obvious examples, each require the services of a surgeon who practices his specialty exclusively.
In addition there are types of specialisation which may be developed within general medicine or general surgery and which are rarely an exclusive interest; the two examples given, however, and that of dermatology in the province of medicine do not "belong to this category.
8. The Distribution of Specialist Services. Throughout this memorandum the term Hospital Centre is used to describe a group of hospitals which together provide for a natural aggregation of population, all the normal specialist services. Whether the hospitals are all in the same town, or one or more of them situated outside it, they may be regarded as having a functional union and may share in a common staff. This does not exclude the possibility that there may be more than one Management Committee in the Hospital Centre. For the treatment of pulmonary tuberculosis, long-stay orthopaedic cases and mental diseases it may be necessary to provide in-patient accommodation at some distance from the main hospital group. General practitioner hospitals included in the group should be visited regularly by specialists for consultations.
9. The term Regional Centre is used to describe the Hospital Centre at the headquarters of the region and includes the Teaching Hospital, although the latter is outside the administration of the Regional Hospital Board, Here will be provided both the range of specialist services which must be available in every Hospital Centre, and in addition those exceptional services which require the collection of cases from a large population in order to make full use of a team of experts who have made those subjects their particular interest. The four principal examples of these are Plastic Surgery, Neurosurgery, Thoracic Surgery and Radiotherapy.
10. It may happen in other fields of work, however, that certain types of case will be referred by specialists to individual colleagues, anywhere in the region, who have acquired a special skill or who have specialised apparatus. For instance, there may be some form of operative treatment for a rare disease which may be developed by one man, working at the Regional Centre or some other hospital centre, to whom these rare cases will be referred from the region as a whole. This sort of association grows up voluntarily and requires no special planning.
11. The Integration of Hospital Services. The main problem of the Regional Board will be to integrate the specialist services of the Regional Centre and the Hospital Centres. In theory there are two possible ways of doing this:
(a) In the first, responsibility for the care of patients in the hospitals throughout the region would be in the hands of a large staff of senior specialists resident in or near the Regional Centre, assisted by specialists of lesser experience working under their direction in the outlying Hospital Centres, None of the Regions, however, is so small that specialists living at the Regional Centre could effectively assume responsibility for the care of all patients in the hospitals of the region. Any attempt to operate such a plan would involve for the senior specialists an expenditure of time in travelling which could not be justified. Furthermore to diminish the responsibility of the staffs of outlying Hospital Centres in this way and to this extent would not be in the interest either of the staffs themselves or of the public of the area which they served.
(b) The second method therefore appears to be the only practical one. According to this plan, the services of a complete range of specialists (except for the four regional services already mentioned) "would be available a1 each Hospital Centre and they would be fully responsible for the hospital treatment of its population. In the smaller Hospital Centres their services would be shared with other centres. Under such conditions, linkage between the Regional and Hospital Centres would "be maintained by recognising all the specialists throughout the Region as members of one team. Members of the staffs of Hospital Centres should, be given, the opportunity to take temporary duty in hospitals at the Regional Centre, and some grades of specialist in the Regional Centre, should similarly have opportunities of doing temporary duty in a Hospital Centre.
12. Specialist Associations. Regular personal contacts between specialists working at the Regional Centre (including the staff of the teaching Hospital) and those working at the peripheral Hospital Centres should be encouraged and facilitated. With this object in view, professional associations in the various specialties should be fostered on a regional basis so that meetings can be arranged at regular intervals for discussion or clinical demonstrations, sometimes at one centre, sometimes at another, probably most commonly at the Regional Centre. It is desirable that the Heads of Departments of the Teaching Hospital and other specialists of the highest standing at the Regional Centre should visit the outlying centres from time to time, to give opportunities for consultation and exchange of ideas -with the specialists working there. It is by this free professional association rather than by formal inspection and supervision that the university centre will both diffuse its own influence and receive outside stimulus.
13. Association through Post-graduate Training. Arrangements for post-graduate education trill provide an additional link between Regional and Hospital Centres. Newly qualified practitioners will, no doubt, get much of their early experience in resident posts at those hospitals with which their Teaching Hospital is associated, For the training of specialists it is anticipated that a series of graded appointments in the hospitals throughout the region will be organised with the cooperation of the Department of Postgraduate Studies of the Medical School, To meet the needs of general practitioners, arrangements for revision courses and clinical assistantships will be made by the University in Hospital Centres approved for this purpose.
14. Registrars. Although this memorandum is not directly concerned with the training of specialists, practitioners in the later stages of their post-graduate training are important members of the staffs of hospitals. Various designations such as registrar, first or second assistant resident medical or surgical officer or clinical assistant are used for the posts held by such men. In this memorandum the term "registrar" is used where it is desired to suggest the employment of officers senior to the house physician or house surgeon grade and considered to be passing through a probationary period of training in a specialty. Some practitioners may start on such a course and, after a period of a year or two turn to training in some other specialist field or to general practice. Others will continue, acquire post-graduate qualifications and ultimately, after a full period of training, emerge as specialists suitable for more senior appointment on hospital staffs. It is not possible to estimate the numbers in either group and as a result estimates of the numbers of registrars given in later sections include both these groups.
15. Specialist Advisers. This memorandum is only a general guide for the assistance of Boards in the development of their specialist services. It will often prove difficult, even impossible to apply the general recommendations given here to particular cases. In these problems as well as in many others the Boards will need advice from experienced specialists in different branches of medicine and surgery. The Boards will therefore probably consider it necessary to appoint a number of part-time consultant advisers from among senior specialists in their Regions to assist in dealing with the problems of individual specialties. Such a course was followed by the Ministry of Health in the Emergency Medical Services and proved a sound policy.
No reference is made in subsequent sections to medical records and the provision of a statistical service for hospitals. Regional Boards may find it necessary to improve the records departments of hospitals, and to increase staff and accommodation in many of theirs. Certain Universities already have Departments of Medical Statistics and may be able to assist Regional Boards.
II. TEACHING HOSPITALS
16. Hospitals designated under the National Health Service Act as Teaching Hospitals have been given a separate identity and status. Their Boards of Governors are required in addition to their primary functions of providing for the sick to provide special facilities for the clinical instruction of undergraduates and postgraduates, and for research by members of the teaching staff, in accordance with the educational policy of the university or medical school concerned. It is highly desirable that there should be the closest association between the University, the Teaching Hospital and the Regional Board hospitals, with a view to the encouragement of research and the training of specialist staff as well as the routine training of students.
17. Undergraduate Education. No medical school attempts to instruct its undergraduates in the diagnosis and treatment of the whole range of diseased conditions and their varieties. The aims of undergraduate instruction in this country have been well described by the Planning Committee on Medical Education of the Royal College of Physicians, as follows "The first object in the undergraduate course should be the teaching of method, method for elucidating the facts concerning disease, method for welding these facts into an understanding and judgment of the question at issue, method for testing the validity of this judgment; for method is a more lasting acquisition than is fact, and without method a man is lost when he meets an unfamiliar situation, as he is ultimately bound to meet it, away from his teacher's guidance. The second object should be the teaching of principle, that is to say the student should be led to understand those phenomena which recur so frequently in disease that they may be said to be of fundamental importance. The two objects should be brought before the students in such a way as to show him that the scientific method can be used in clinical study - that there is such a thing as clinical science.
18. In view of its special functions the Teaching Hospital may not be able to undertake all varieties of treatment and special investigation. It will inevitably share obligations under these headings with the hospitals of the Regional Board. The number of beds for which its Board of Governors assumes responsibility will be mainly determined by considering the optimum number which will enable it to perform its teaching and research functions efficiently.
19. There will be some selection of the cases admitted to a Teaching Hospital so that suitable cases may be available for undergraduate and advanced education and for the needs of research. This selection will be principally effected in the outpatient clinics, but members of the staff of the teaching Hospital who hold appointments in other hospitals will be able to assist in this matter and it will also be served by general collaboration between the staffs of the hospitals of the region. This collaboration is particularly important in relation to clinical research; it should extend over the whole hospital system of the region and may even cross regional boundaries.
20. It is not possible for the Teaching Hospital alone to provide all the clinical material required for undergraduate and postgraduate teaching. In particular arrangements will have to be made by the University or Medical School with the Regional Board for the use of facilities for instruction in tuberculosis^ infectious disease and mental disease. In addition it will often be necessary to make similar arrangements for instruction of students in other subjects. There should be no difficulty in making such arrangements, given the cordial relations which should exist between the two boards.
21. Postgraduate Education. The organisation of postgraduate education is primarily the responsibility of the University with which a Teaching Hospital is associated. For the effective administration of the policies adopted by the University there must, however, be the closest co-operation not only between the University and the Teaching Hospital but between both these and the Regional Board and Hospital Management Committees.
22. Postgraduate education may at present be divided into four categories:-
(a) Graded appointments for the training of specialists.
(b) Courses of instruction for intending specialists from this country and abroad
(c) Advanced revision for established specialists.
(d) Regular teaching sessions and periodic refresher courses for general practitioners
23. The training of specialists will be effected by the provision of suitably graded posts in the departments of the University, the Teaching Hospital and hospitals of the Regional Board.
24. Facilities for the second and third category of postgraduate education may be net (a) in special departments in Teaching or Regional Hospitals and (b) by the designation of postgraduate Teaching Hospitals.
25. The former method will be that usually followed in the provinces, but in London, in addition Teaching Hospitals will be established in association with the Postgraduate Medical Federation and its special Institutes.
26. Refresher courses for general practitioners should be provided in those hospitals under the Regional Board which have been approved for this purpose by the University. Constant contact between general practitioners and hospitals will, of course, be encouraged.
III. GENERAL MEDICINE
27. Even the smallest Hospital Centre will need at least one general physician living locally. This is necessary in order to ensure continuity of supervision and the economical use of hospital beds, and also to deal with medical emergencies. In these small Hospital Centres the specialties, other than general medicine, general surgery and obstetrics and anaesthetics may be covered by visiting specialists from neighbouring larger centres.
28. To avoid isolation in his specialty, every specialist working at one of the smaller centres should also be actively associated with a larger centre. A member of the hospital staff in the larger centre should be available to take over his duties during holiday periods or sickness. This principle of relief is applicable to all specialist services throughout the region so that a physician's responsibilities are automatically taken over by a colleague of specialist rank and not delegated to junior medical officers,
29. The general physician will be expected in future to give an increasing amount of time to the care of the chronic sick as part of his normal duties. Admission to wards for the chronic sick should always be by way of the wards or hospitals for acute cases, and it is to be expected that facilities for the rehabilitation of the chronic sick will be better and more general than they now are; the work will be largely supervised by the general physician.
30 It is difficult to give any accurate estimate of the number of general physicians required to maintain a satisfactory specialist service. Much will depend on the extent to which general medicine may become partially sub-divided. General medicine should not ordinarily embrace paediatrics or dermatology; some general physicians may elect to give part of their time to paediatrics, but there should, nevertheless be a paediatrician visiting each Hospital Centre. General physicians will, however, almost certainly need to undertake some neurological and cardiological work. The group of muscular and articular disorders included under the general heading of rheumatism causes a large amount of ill-health and loss of working time. In some regions active measures are already being token in the investigation of this group of diseases special diagnostic and research centres with out-patient facilities and beds at general hospitals in the Regional Centres and beds for long-stay cases in associated hospitals have been established. The subject calls for special attention from physicians and specialists in orthopaedic surgery and physical medicine and it may well become the special, though rarely the exclusive interest of a physician. Some of the large spa hospitals may provide useful accommodation for long-stay cases, provided they are closely linked with the work of general hospitals...
31. For a population, of 100,000 - 120,000 in an area served by one Hospital Centre, it is probable that some 250 medical beds mil be required, apart from those for the chronic sick, tuberculosis and infectious diseases. Estimates of the number of physicians needed for such a centre can only be approximate. Account mil have to be taken, inter alia, of the respective amounts of hospital and domiciliary work to be done, of whether the physicians are employed wholly within the service or on a part-time basis, and of the various gradations in seniority among the physicians. Bearing these conditions in mind, it is suggested tentatively that the medical staff of a centre with a group of 250 medical beds and beds for chronic sick might be -
3 general physicians of senior grade (half-time)
3 general physicians of junior grade (half-time)
Not less than 3 medical registrars (whole-time)
If any of the physicians devote the whole of their time to duties at this centre the numbers will necessarily require modification,
32. It is undesirable that general medicine should be so rigidly sub-divided that all the cardiological or neurological work becomes concentrated in the hands of specialists engaged only in these subjects. The general physician should be kept in contact with men working in these fields and, of course, with colleagues in general medicine from other centres and, particularly the university centre. Associations of physicians on a regional basis to include those working in the specialties should be encouraged. Neurologists, cardiologists and other specialists of this kind at the Regional Centre (or at major Hospital Centres which are virtually the equivalent of a Regional Centre), should be available for consultation by their colleagues at the periphery.
IV. GENERAL SURGERY
33. As in general medicine, so in general surgery, it is essential that every Hospital Centre should have a locally resident specialist. Since the acute emergency requiring immediate active intervention is commoner in surgery than in medicine, it is desirable that there should be at least two surgeons resident in each centre, although in the smallest centres one or both men may spend part of their time working elsewhere. As in all the other specialties, it is of the utmost importance that a man should be kept in touch with the work of colleagues; the comments made above about the desirability of professional associations of physicians apply with equal force to surgery.
34. General surgery tends more and more to be broken up into special branches. It should, for instance, no longer embrace gynaecology, even in the smallest Hospital Centres. There may be occasions when a gynaecological emergency is dealt with by a general surgeon, as for instance when the initial diagnosis is uncertain, but apart from this, gynaecology should be regarded as a distinct specialty. Similarly, orthopaedic and traumatic surgery constitute a specialty for which separate provision should be made in each Hospital Centre and this provision should include arrangements for dealing with emergencies.
35 In some branches of surgery specialism goes further than in others; for instance, in genito-urinary surgery there is much more marked tendency to separation than in gastroenterology. The time is hardly ripe for separating genitourinary work entirely, except perhaps at Regional Centers. It seems more likely that, as in the case of medicine, each hospital Centre will be served by a team of general surgeons, each of whom may develop a special interest. Thus, the surgeon who acquires particular skill in the operative treatment of diseases of the stomach may still continue to undertake other abdominal surgery. In the large centres there may be more than one surgeon specialising in each of the branches mentioned.
36. Neurosurgery, Plastic Surgery and Thoracic Surgery are much more sharply defined as specialties. It may be necessary for the general surgeon occasionally to deal with a neurosurgical emergency or some very urgent thoracic condition, but the majority of these cases will be handled, in future, by surgeons giving all their time to the specialty.
37. In estimating the number of surgeons required same factors rust be taken into account in determining the appropriate establishment as were considered in the case of physicians. Although in surgery- fewer domiciliary consultations my be necessary, this may be more than. balance the claims of urgent operative work.
38. Bearing these conditions in mind, it is suggested. tentatively that to serve a population of 100,000-120,000 ,-% group of 180 surgical beds should be provided and that these will require the services of:
3 general surgeons of senior grade (half-time)
3 general surgeons of junior grade (half-time)
Not less than 3 surgical registrars (whole-time)
If any of the surgeons give the whole of their time to work at this centre, adjustment will be needed.
39. It will be appreciated that the chronic sick., though requiring surgical attention on occasion, do not need the same amount of supervision by surgeons as by physicians.
V. OBSTETRICS and GYNAECOLOGY
40. These two allied subjects constitute one specialty, although, rarely, a specialist may concentrate on one or the other side. As the service develops, gynaecology will cease to be undertaken by general surgeons.
41 Midwifery alone, on the other hand, is not a service restricted to specialists. It is contemplated that a domiciliary service will be provided under Parts III and IV of the National Health Service Act by midwives and general practitioners with experience in midwifery. In addition Local Health Authorities will continue to provide ante-natal and post natal clinics. Institutional midwifery will be the responsibility of the hospital and specialist service, which will need also to provide specialist aid for domiciliary emergencies, consultative ante-natal and post-natal clinics (normally at the hospitals), and beds for abnormal cases.
42 It is clear from the foregoing that co-ordination of the three branches of the Suggestions on this matter will be made to Regional Boards in a separate memorandum.
43 the number of maternity beds theoretically required for a given population varies with the birth rate, but for some years to come all the beds which can be made available and staffed will be necessary. It is probable that, in present conditions of housing and availability of domestic staff, the great majority of women would elect to be confined away from home. Certainly the aim should be institutional provision for at least three quarters of the births. A population of 100,000 would, therefore, require 60 to 75 lying-in beds, (as the birth rate ranges between 16 and 20), and about 30 ante-natal beds.
44 The main maternity units should be at general hospitals rather than in separate maternity hospitals. A unit of 100 beds is considered the ideal, but a larger department of perhaps 200 beds forming part of a general hospital be satisfactory, if suitably divided and adequately staffed. It is probable, however, that in large urban areas, with a population exceeding a quarter of a million, conveniently placed separate homes of about 40 beds will be established for normal cases. Although these separate units may be enough to have resident medical staffs, they should be under the supervision of the obstetric staff of the main unit. In small towns-which have no Hospital Centre, units as small as 20 beds may be provided under the supervision of the general practitioner obstetrician'° with the obstetric specialists visiting from the nearest Hospital Centre.
45. It is estimated that one gynaecological bed is required for a population of 4,000. The Hospital Centre serving 100,000 population would, therefore, require 25 gynaecological beds but this number would have to be increased to provide for abortions and about 5 additional beds would be needed for this purpose.
46. The Hospital Centre with 100,000 population would, therefore, require a total of some 90 maternity beds, including ante-natal beds, and 30 gynaecological beds including those for abortions. The staff required for such a group would be 2 half-time or one whole-time obstetrician and gynaecologist and 1 registrar - whole-time - with other senior and junior resident medical staff.
47. Both the gynaecological and obstetric work should be closely associated with other specialist services. The paediatrician should be in charge of the babies in the nurseries of maternity units. Physicians should supervise the treatment of certain cases, e.g. patients with heart disease in ante-natal wards. Pathological and biochemical services, including facilities for endocrine investigation, must be available. The gynaecological out-patient service should include the provision of Infertility Clinics.
48. Paediatrics is, briefly, medicine applied to the maintenance of health and the treatment of disease in children. For this purpose children may include persons up to the age of fourteen.
49. Fully staffed paediatric departments, distinct from those of general medicine, should be provided in every Regional Centre, usually associated with a University Institute of Child Health. A paediatric department should also be established in every larger Hospital Centre, not as a subsidiary to that of the Regional Centre, but as an independent special department, responsible for the care of all children's medical wards in the area. There will also be centres which are too small to provide sufficient work for a locally resident paediatrician and in these a service should be provided by a visiting paediatrician, even though there may be available general physicians with a special interest in paediatric work.
50. It is of the utmost importance that hospitals or wards for infectious diseases should be closely associated with paediatric departments, since so many of the patients are children and the problems are similar. Equally, the work of orthopaedic surgeons, cardiologists and tuberculosis specialists must be co-ordinated with paediatrics. Paediatricians should have the oversight of nurseries in maternity units.
51. It is also important that paediatricians working in hospitals should be associated with the preventive clinic services for children which are maintained by the Local Education and Health Authorities. This is especially desirable at the university
52. In the larger centres separate children's hospitals may continue their separate existence, or a self-contained children's unit should be provided in a general hospital gropup. A self-contained unit is much easier to administer from the point of view of nursing staff and tends to attract the type of nurse specially interested in children. In the smaller centres the children's unit should be art of the general hospital. It is particularly important that the beds in all such units should be in the charge of the visiting paediatrician.
53 It is desirable, as in other specialties, to encourage an association of the paediatricians working in outlying centres with the university centre. The number of men engaged in this specialty will be much smaller than in general medicine and there is, therefore, a greater likelihood of isolation unless care is taken to ensure that the influence of the Regional Centre extends to the periphery.
54 The number of hospital beds which should be provided far children has been given as 0.5 beds per 1,000 of population, but this is probably insufficient. The number of whole-tine paediatricians required, according to the British Paediatric Association, is about six to eight per million of population, but the number available at the present time falls very far short of this and it will be some years before there are sufficient fully trained men to meet the needs of the country. On the basis of these proposals it is suggested for the standard population of 100,000-420,000, 50 general children's beds should be provided. As to staffing, the services of one half-tire paediatrician with a whole-time registrar would be the minimum for such a populations
55 The surgery of diseases of children is not a separate specialty in the same any as children's medicine. It is usual and beneficial for surgery in children to be a special interest of some general surgeons, but there is not the same distinction between surgery in the child and in the adult as between paediatrics and general medicine. Other specialties, such as ophthalmic and orthopaedic surgery, should be in the hands of the same specialists as for adults.
56. Pathology which includes morbid anatomy, biochemistry and haematology, must be organised in every Hospital Centre as a specialist service. This need not embrace the provision of facilities for Public Health bacteriology, because a separate Public Health Laboratory Service is being instituted for that purpose, Where there is no Public Health Laboratory in the vicinity, however, public health bacteriology may have to be done by the hospital staff in the hospital laboratory, by arrangement between the Regional Board and the Public Health Laboratory Service, it is essential that close contact should be maintained. between hospital laboratories and Public Health laboratories and it may often be convenient and desirable to house them in the same building.
57 Pathology is a completely defined specialty which should not be practised in conjunction with general medicine or with any other clinical branch. A pathologist should he available for consultation and should supervise the laboratory work in even the smallest Hospital Centres. In centres serving a population of less than 50,000, there may not be enough work for a pathologist living locally; in these cases the routine work should be done by a technician supervised by a pathologist visiting regularly from a neighbouring centre. Calls on the laboratory service will certainly increase and eventually even these smaller centres may need at least one pathologist. In no case should a hospital rely on a postal service or on the services of a technician not under the supervision of a pathologist.
58. In the larger Hospital Centres there will be laboratories employing more than one pathologist. If there are several hospitals in a centre it is generally desirable that there should be one co-ordinated service of pathology for all of them. Where there is work for more than one pathologist, it is desirable to develop some further degree of specialisation, in the branches of pathology. Smaller centres, by grouping with each other or with neighbouring major centres, may also develop some degree of specialisation, as each individual pathologist may have his own particular interest. But such arrangements should not preclude the reference of specimens for further opinion when necessary, to the university or other large laboratory.
59. The laboratory must be brought into the closest possible touch with clinical work. Both clinician and pathologist have much to gain by consultation in the wards, the laboratory and post-mortem room. The pathologist should always be responsible for conducting autopsies.
60. In pathology, even more than in most other specialties, it is necessary to develop close links between the 3egional Centre and the other Hospital Centres. The quality of laboratory work depends very largely on the contacts between. the individual workers and regular meetings of the pathologist of the Region, including those in the University Department of the Teaching Hospital, should be arranged.
61. Machinery will be needed for providing advice on pathological subjects to the Regional Board, and this might consist of a committee of pathologists, of whom one should be Adviser in Pathology to the Regional Board.
VIII. MENTAL HEALTH SERVICE
62. The suggested framework for the organisation of the Mental Health Services is set out in greater detail in R.H.B. 47/13. The following paragraphs indicate generally how those services will dovetail with the other hospital and specialist services of the Regional Board. Owing to the special problems of the Mental Health Service, each Regional Board will require on its central staff a psychiatrist to act as its adviser for Mental Health. He will be responsible for the co-ordination of the specialist services for mental health throughout the region and his function will be to co-ordinate - not to dictate. Although much of his work will be administrative, it is desirable that he should retain some direct contact with clinical work.
63. The regional psychiatric service will be based mainly on the mental hospitals, which will usually serve large groups of population. The number of beds required in mental hospitals is estimated to be 3.8 to 4. per thousand of population. The present size and distribution of mental hospitals derives largely from local government affiliations and will be modified with the passage of time. The desirable maximum number of beds in a mental hospital is considered to be 1,000; there will thus be a need for 3 to 4 such hospitals for a population of 1 million. The number of specialist psychiatrists, exclusive of junior assistant staffs, required far a nor-teaching hospital of a thousand beds including its outpatient service and domiciliary work, is of the order of five.
64. All psychiatrists at mental hospitals should be associated with the out-patient work for the area served by the hospital. It is not considered desirable that psychiatrists should have experience only of in-patient or only of out-patient work. The out-patient service will be provided as part of the out-patient activities of the Hospital Centre, and clinics will usually be held in the out-patient departments of general hospitals. These clinics will be staffed by psychiatrists from all available sources. There size will vary with the range of work undertaken, but even at the smaller clinics with limited scope, which may well be affiliated with the larger centre, there should be at least 2 doctors working part-time and the necessary ancillary staff.
65. Some beds should be available in the general hospitals where clinics are held. These beds would be used for patients who do not show marked behaviour disturbances and who require admission for a limited period for diagnosis or short term treatment.
66. In addition it is probable that increased use will be made of Neurosis Centres for patients suffering from early and milder forms of mental illness not requiring admission to mental hospitals under the Lunacy and Mental Treatment Acts. Such centres might be established in association with mental or general hospitals or alternatively a larger centre could be set up to serve hospital areas.
67. It can be assumed that at every Regional Centre the University will provide a teaching psychiatric unit which should be in close liaison with the appropriate mental hospital and it is desirable that the Professor of Psychiatry at the Teaching Centre should have access for teaching purposes to mental hospital beds. It is not anticipated that there will be any difficulty in arranging, by agreement, for the necessary clinical facilities to be provided. Conversely, and to everyone's mutual advantage the medical stuff of the mental hospital should participate in the work of the teaching psychiatric clinic.
68. It is essential that psychiatrists should be in close contact with specialists in other fields. They should be available for consultation freely in the general hospitals and should make use of other specialists for consultation on cases in mental hospitals. The increased use of neurosurgery in the mental illness suggests the desirability of selecting certain mental hospitals for the treatment and rehabilitation of suitable patients. These hospitals should be near Neurosurgical Centres.
69. The mental health of children will be the concern partly of the education authorities and partly of the Regional Board. Local Education Authorities will setup child guidance centres under the supervision of the school medical officer or the educational psychologist. The services of a psychiatrist will be required for diagnosis and advice and to carry out short-term treatment. The Regional Board will set up clinics for child psychiatry= to deal with cases which are medical rather than educational and will carry out long-term treatment.
70. It is hoped that these two types of clinic wall t closely associated through the expert staff. Child psychiatric clinics will usually be located where paediatric cling are provided and it is important that there should be cooperation between the paediatrician and the child psychiatrist. In-patient treatment for children will be provided through Regional Board.
.71 Care of mental defectives. The burden of the care of defectives falls partly on the local health authorities and partly on the Regional Board. Local Authorities will responsible for the ascertainment of defectives and the care of defectives in the community other than those who are on leave or licence from institutions. Children of school will normally be "ascertained'' only when they are reported the Local Education Committee for the purposes of the Mental Deficiency Act, 1913, on the ground that they have been found incapable of receiving education at school.
72. Provision of institutional care is made by the Regional Board and it is probable that the ultimate number beds required will be about 2 per thousand of the general population. Colonies vary much in size and stage of development. The smallest complete colony in which satisfactory classification is possible will have about 800 beds; the maximum size should not exceed 2,000 beds.
73. Colonies are under the supervision of specialist in mental deficiency and it is desirable that their special knowledge should be utilised in adult clinics and in child guidance work.
74 The practice of anaesthesia has been highly developed in marry of the larger centres in. this country but has not been widely enough recognised as a specialty.- The administration of an anaesthetic is a major procedure and for the most .:art anaesthetics should be given either by specialists, or under the supervision of specialists, or by medical practitioners with special experience. To avoid anaesthetic complications all anaesthetics should, as part of their responsibility, co-operate in any necessary pre-operative treatment and post-operative care. It is of particular importance that experienced anaesthetists should be available for the administration of anaesthetics in emergency cases, whether by day or night, since these are often the worst operative risks and in special need of skilled attention.
75. Anaesthetics for obstetric cases in hospital should be given by practitioners with experience and the same rule should apply to dental and casualty work. Even though full specialists may not undertake all this work, it should not be lightly left to men whose experience has been limited. The specialised techniques of Neuro-Surgery, Thoracic Surgery and to a less extent of Plastic Surgery require correspondingly specialised anaesthetic techniques, and skilled anaesthetists should be attached to these departments to meet their particular needs.
76. At present there are far fewer specialists in anaesthesia than are required, if a full service is to be provided, a staff of 2 specialist anaesthetists whole-time, or the appropriate equivalent part-time, with 2 registrars and 3 resident anaesthetists - all whole-time - should be provided for a Hospital Centre serving a population of 100,000-120,000. proportionately greater numbers would be needed at centres where special services such as neurosurgery are available.
77. At each Regional Centre there should be a special unit for the study of all problems connected with the heart and vascular system. The regional cardiovascular unit will be recognised as the clinic to which patients can be sent for a second opinion and for special investigation and treatment. It need not be a large unit and should not be responsible for the diagnosis and treatment of all cardiovascular disease throughout the Region.
78. The routine diagnosis and treatment of cardiovascular disease will be in the hands of the general physicians is the various hospitals in the region and patients suitable for reference to the Regional Centre will be selected by those physicians.
79. It should be possible for members of the staff of the central unit to visit regional hospitals from time to tine and in that way maintain the standard of cardiovascular work throughout the region. In the larger hospitals in more concentrated areas of population a local physician may develop a special interest in cardiology and be able to form an associated cardiovascular unit.
80. The functions of the staff of the central unit might be summarised as follows:
(1) To act in a consultative capacity in all questions concerning cardiovascular problems in the region. Cases would be referred to the unit from other specialist physicians and special departments' e.g. Department of Child Health, Thoracic Surgery, Neurosurgery and Obstetrics.
(2) To undertake the treatment of a number of cases of cardiovascular disease, more especially from the standpoint of research into the methods of diagnosis and treatment and also to provide clinical material for teaching.
(3) To undertake research into cardiovascular physiology pathology and therapeutics.
(4) To afford clinical teaching in cardiovascular subjects, properly integrated with the curriculum in general medicine, for undergraduates and especially post-graduates in the University of the region.
81. To carry out these various functions the regional cardiovascular unit should be situated in close proximity to those special departments with which co-operation is desirable. In some regions the Teaching Hospital may not be able to supply all the necessary accommodation and the requisite number of beds, and where this is the case a nearby hospital could be utilised. For the investigation and treatment of in-patients about sixty beds should be available - thirty for men and thirty for women.
82. The department, like any special department, would require a waiting room, examination rooms, rooms for the medical staff, and in addition screening and electrocardiographic rooms and the necessary accommodation for clerks, technicians and the keeping of records. Some departments of this character already exist in London and the provinces, and deal with large numbers of outpatients. Laboratories for physiological and pathological research should be readily available.
83.. The staff required for the running of such a department, including both in-patients and out-patients, should be under a physician-in-charge, assisted by a deputy. Either the physician or his deputy should be employed whole time. At least one whole-time registrar would also be required.
XI DENTISTRY IN HOSPITALS
84. The value of dental treatment as an adjunct to certain forms of medical treatment is not sufficiently appreciated and it is only rarely that a hospital provides adequately for dental care. Those hospitals which do provide dental :treatment too often limit it to emergency measures.
85. The hospital service should in future provide a wider range of dental care of in-patients. Full dental treatment is not practicable for all cases admitted to a general hospital, especially when the duration of stay is short but it should be provided in all long stay hospitals. 17here time allows, however' and particularly when the health. of the patient is directly affected by his dental condition, it is desirable that a state of dental fitness should be achieved while he is under treatment. For such patients$ facilities for full conservative dental treatment and not merely for extractions should be provided.
86. With a fully equipped department able to deal with all ordinary forms of dental care, one whole time dental surgeon should be available for each 500 hospital beds to ensure adequate dental care for all patients. T=e should be assisted by one or two dental house-surgeons, one of whom in -the larger hospitals should be resident.
87. In addition to this provision for routine dental care, two or three beds should be provided in every Hospital Centre for patients needing major dental operative treatment; in a general hospital of 1.000 beds, three should be set aside for each sex for this purpose. It is advisable that a dental surgeon specialising in oral surgery should be available in a large centre or for a group of smaller centres. One such specialist. working whole-time, would probably meet the needs of a population of about 300.000; he might supervise generally the work of the resident dental staff, some of whom might be specialists in training.
88. Within each region facilities must be provided for dealing with faciomaxillary injuries and diseases and injuries in which close collaboration between dental surgeon, general surgeon and plastic surgeon is needed. Further reference to this will be found in the section dealing with Plastic Surgery.
89. At the present time fully trained dermatologists are only found in large centres of population, although in some centres general physicians or general practitioners with considerable experience in the subject have staffed dermatological clinics. An efficient dermatological service cannot be maintained without specialist staff. It may be some years before a sufficient number of experienced dermatologists will be available to meet the needs of all Hospital Centres., but it should be the aim to provide such a complete specialist service as soon as fully trained staff can be provided,
90. The greater part of the dermatological service is provided in the out-patient department, &nd clinics should be held at all Hospital Centres. Beds should be available in association with out-patients clinics, but in the smallest Hospital Centres the number needed would not justify a separate unit. Ten beds for each sex should be ample provision in a Hospital Centre serving a population of 100..000 and no unit should be smaller than this. Separate hospitals for diseases of the skin are undesirable, except as part of a special postgraduate training and research unit, as contemplated in London.
91, Four dermatologists giving at least half their time to hospital work would probably be needed for every million of population and one dermatologist could undertake the work at two centres, each serving 100,000-120J.000. Large groupings are preferable so that there can be adequate provision for reliefs and for contacts with others working in the same specialty.
92. The out-patient service should provide facilities for daily treatment of patients., on the prescribed lines, by specialty trained nurses and male orderlies. Provision for radiotherapy and actinotherapy should be concentrated at the larger Hospital Centres. Radiotherapy should be prescribed by the dermatologist but the apparatus should be calibrated and supervised by the radiotherapist and physicist. It is essential that there should be co-operation in this work. There will be some radio therapy for skin conditions, e.g. for malignant dermatoses, which is properly the province of the radiotherapist.
93. Special provision for the treatment of lupus will be required. Each Regional Centre might have a unit for the treatment of this disease by special forms of actinotherapy, but it is probable that residential accommodation need not be provided in more than two centres in the whole country.
94. Provision for teaching must be made at the Regional Centre. It will probably be necessary to have a demonstration unit with say 20 beds in the Teaching Hospital with the balance in the beds in the hospitals of the Regional Board. Staffing should be on generous lines to allow for teaching, most of which would be undertaken in the out-patient department.
XIII. DISEASES OF THE CHEST
95. The in-patient and out-patient services for tuberculous patients, now provided at sanatoria and tuberculosis dispensaries, will become part of the Regional Board's hospital service. The future service should provide in-patient facilities, partly in special sections of general hospitals and partly in sanatoria, under the care of specialists in diseases of the chest. The out-patient service should be related to these in-patient units and should be established, where possible, in a section of the out-patient department of the Hospital Centre. In rural areas it will be necessary to keep some outlying dispensaries for the convenience of patients. The specialist staff will be available for domiciliary consultations.
96. In the past, tuberculosis officers have tended to work too much in isolation from the main body of general medicine. Pulmonary tuberculosis should be regarded as the field of physicians, trained primarily in diseases of the chest, who have made a special study of this, one of the commonest forms of disease of the lungs. The training of the specialist chest physician. should be in line with that of other specialist physicians, with the sound background of a training in general medicine prior to specialisation in the diagnosis and treatment of diseases of the chest.
97. It is essential that specialist officers undertaking work at out-patient clinics should also be in charge of the beds for pulmonary tuberculosis in sanatoria and general hospitals. This is necessary not only to maintain the quality of the work of the individual specialist but to give continuity in the supervision of treatment. It may be that, in larger sanatoria, a resident physician will give less of his time to outpatient work and more to the supervision of inpatients, especially where the other physicians have to live in areas where they hold their out-patient clinics, at some distance from the sanatorium.
98. It is undesirable that the treatment of tuberculosis should be divorced from the treatment of other medical conditions of the chest, even if separate institutions or wards are used. The chest physician undertaking tuberculosis work must be freely available for consultation in the general hospitals of the centre to which his sanatorium beds are related. Reference to the surgical treatment of pulmonary tuberculosis is made in the section on Thoracic Surgery; it is sufficient here to mention the necessity for regular consultation between chest physicians and chest surgeons.
99. The chest physician dealing with tuberculosis must necessarily concern himself with the epidemiological and social aspects of the disease. He will work in close cooperation with the paediatrician. and orthopaedic surgeon and rill be associated in the diagnosis and treatment of nonpulmonary tuberculosis. He should collaborate with the Medical Officer of Health of the Local Health Authority on the preventive and social aspects of the disease. The attendance in the tuberculosis clinics of the Health Visitors of the local health Authority will help to secure further co-operation. Further guidance on the collaboration between Regional Hospital Boards and Local Health Authorities will be provided in due course.
100, There is much to be said for the view that in all radiological work for diseases of the chest the specialist radiologist should be associated. This does not mean that chest physicians would cease to screen their patients. They would naturally continue to do so, but it would be an essential feature of the arrangement proposed that the advice of the specialist radiologist would be available at all times, and that he should see and express an opinion on all radio graphs of the chest and its contents. The same association is necessary in mass miniature radiography work and in this the Medical Officer of Health gill also be closely concerned on the epidemiological aspect.
101. The Regional Board will need appropriate advisory machinery in this speciality. A member of their central regional. staff trill be needed to give at least part of his time to the administrative aspects of the tuberculosis scheme, although it is important that he should retain an active clinical interest in this subject.
102. A population of 100,000-120,,000 will need more than one chest physician. it is probable that the number required gill be of the order of 15 per million of population, working whole-thne9 with appropriate staff of registrar grade, mainly employed in hospitals and sanatoria but also undertaking outpatient work under supervision.
103. Sanatorium units should serve a large population and should have a minimum of 200 beds, but the general hospital serving a population of 100,,000-120,000 should have a unit of about 20 beds for the investigation of patients in whom the diagnosis is doubtful. In addition, small units for advanced cases may be placed in various hospitals.
XIV. SURGERY OF THE EAR, NOSE AND THROAT
104. The surgical treatment of diseases of the ear, nose and throat, is properly the province of a surgeon who restricts his practice to this specialty. Every Hospital Centre should have an ear, nose and throat department, including out-patient and in-patient departments. Beds should be provided in separate ward units., not mixed with general surgical beds, so that nursing staff acquire special experience and skill in the management of these cases.
105, It is undesirable to establish special Ear, Nose and Throat Hospitals. A separate ear, nose and throat unit in a hospital group may be desirable but the usual arrangement would be the setting aside of a self-contained unit or a floor in a general hospital. The nature of the acute infections of the ear, nose and throat is such that it is highly desirable to have a large number of single bed wards in any unit provided for these conditions. The preponderance of children treated in this branch of surgery also makes desirable the provision of a substantial proportion of single-bed wards. In larger Hospital Centres it is also an advantage to have separate operating theatres.
106. Although an ear, nose and throat department is necessary in every Hospital Centre it does not follow that there will be sufficient work for a locally resident Special ist in the smallest Hospital Centre. Z1herever possible a locally resident specialist should be provided. Otherwise, a specialist should visit at regular and frequent intervals from the nearest larger centre. An experienced senior resident officer should be available and the specialist should be on call, In extreme emergency one of the locally resident general surgeons might have to take immediate responsibility for urgent treatment.
107, In larger Hospital Centres there may be more than one acute general hospital and a separate infectious disease hospital, children's hospital and sanatorium. An ear, nose and throat surgeon should be on the staff of each of these hospitals and, in particular, should be responsible for the treatment of appropriate cases in isolation hospitals. An attempt should be made to concentrate the bed provision for ear, nose and throat cases at one or at most two of the hospitals. Where there is a central hospital with the min out-patient department and a peripheral hospital with the majority of the beds, it may be necessary to divide the inpatient accommodation but one in-patient unit should be provided where possible.
108. In some large towns there are separate clinics with a few beds where operative treatment for tonsils and adenoids is undertaken these should be abandoned as soon as possible and proper facilities and accommodation for an adequate stay in hospital before and after operation should be provided.
109. Special provision will be needed for the treatment of deafness. Arrangements are in hand for the production and supply of a new standard hearing aid and these should be provided through out-patient departments with appropriate facilities for examination of patients and for the prescription and adjustment of the apparatus. A further memorandum on the provision of hearing aids will follow.
110. A hospital Centre serving a population of 100,000 - 120,000 will require about 50 beds for ear nose and throat cases. The staff required for such a population group would be at least one whole-time surgeon or the part-time equivalent and one registrar whole-mime. This however may be an underestimate and it may prove that three specialists and two registrars are required for two such Hospital Centres.
X V. INFECTIOUS DISEASES
111. Provision for the treatment of notifiable infectious diseases has been the responsibility of Local Authorities in the past and specialist experience in the treatment of these diseases has been very largely confined to whole-time medical officers. It is probable that Regional Boards will wish to re-group the accommodation for infectious diseases, making use either of special sections of general hospitals, or in the largest towns, of separate hospitals associated with general hospitals. The isolation section at a Hospital Centre should be regarded as accommodation available for the isolation of any suitable type of case and not solely for the treatment of patients suffering from notifiable infectious disease. The care of a patient thus isolated because of some non-specific infection should remain in the hands of the appropriate specialist e.g., the gynaecologist in puerperal sepsis.
112. It is presumed that initially a number of whole-time medical officers from the larger infectious diseases hospitals will be transferred to the staffs of Regional Boards. Some of these officers will be of specialist standing and well able to take their places as members of the specialist staff of the Hospital Centre
113. In the smaller hospitals for infectious diseases the supervision of patients suffering from infectious disease has often been undertaken by part-time officers who may also be district Medical Officers of Health or general practitioners. It will probably be necessary to continue arrangements of this kind for a time., but a primary object of the re-grouping of hospitals should be to secure that specialists in the treatment of infectious diseases are available for consultation at the small centres where there are no whole-time specialists.. The aim should be to secure that the patient suffering from an infectious disease is under the supervision of a specialist. It will also be necessary to ensure that resident medical officers are available for all infectious disease hospitals except perhaps where a small remote isolation hospital must continue for the time being owing to lack of more central accommodation.
114 The majority of patients in infectious disease hospitals are at present children; but the changing age incidence of some diseases and the use of isolation accommodation for other infections may change this. It is difficult to see to what extent in future the clinical care of patients suffering from infectious diseases may become merged in the provision for other diseases of children or of medical conditions generally. It may be that in the distant future this specialty will be in the hands of paediatricians with a special interest in the treatment of infectious disease or of general physicians with a similar bent. In any event the paediatrician should be closely associated with this work. The otologist should also be called in to treat patients with otitis or other complications of infectious disease coming within his province.
115. It is important that specialists in infectious disease employed by the Regional Board should be available to general practitioners for consultation on the diagnosis of cases before their admission to hospital. The Medical Officer of Health has a special statutory responsibility in. relation to the recognition and control of infectious disease, but the advice of a clinical specialist should always be- available to him. Equally, of course, to aid him in his preventive work, the Medical Officer of Health must have free access to all necessary information about patients in infectious disease hospitals.
116. A population of 100,000-120,.000 might not require the whole time of one specialist in this subject. A large centre serving a population of 500,000 might have a hospital unit of 300 or more beds and a staff of three whole-time specialists who could also supervise the work of senior residents in one or two associated centres. The extent to which this specialty gradually merges into general medicine and paediatrics obviously affects the size of the staff required.
NEUROLOGY AND NEUROSURGERY
117. These two specialties will always be linked together in a regional service, and psychiatry will be closely associated with them. The peculiar administrative problems of psychiatry, however, have caused it to be considered under the separate heading of the Mental Health Services. Ideally Neurology, Psychiatry and Neurosurgery should be included together in one department, but even in the Regional Centres such a comprehensive arrangement is not likely to be feasible for some years.
118. Medical Neurology: There are not yet enough neurologists to provide a complete neurological service and it will be necessary at first to make use of physicians who do not restrict their practice entirely to this specialty. There should, however, be neurologists at the Regional Centre who devote the whole of their time to neurology.
119. The first essential is to create a neurological department at the Regional Centre. It is unlikely that all the beds needed for the region can be provided in one hospital and still less likely that the needs can be met by the teaching Hospital alone. A demonstration unit could, however, be established in the Teaching Hospital, with a much larger number of beds in another hospital. In the larger regions subsidiary units may ultimately be needed at Hospital Centres. These may be instituted in the first place by specialists from the Regional Centre holding out-patient clinics and transferring cases for in-patient treatment to the Regional Centre or, where conditions permit, providing for their care in beds at the Hospital Centre, in charge of a general physician with a special interest in neurology. All patients admitted to hospital with nervous diseases cannot be directly under the care of a neurologist, but it is necessary to ensure that a neurologist is available for consultation.
120.It may be possible for one unit at the Regional Centre to maintain a consultative service for the whole region, but generally neurologists should be provided at Hospital Centres serving large concentrations of population.
121. It has been suggested that from 100 to 150 beds per million of population should be available for neurological cases, including those which are chronic and stay in hospital for long periods. The staff required at the Regional Centre will vary with the size of the region because, in the early years at least, they will be responsible not only for inpatient and out-patient duties at the centre, but for consultative clinics at Hospital Centres. Their services will also be needed in advising on the rehabilitation of certain of the chronic sick. At least one senior and one assistant neurologist giving at least half of their time will be needed for every 50 beds; They will be assisted by such whole-time registrar and junior staff as may be necessary.
122. Neurosurgery: The requirements for organising a service in this specialty are much the same as for neurology and the plan should follow the same general lines
123. A strong team at the Regional Centre is essential and it is preferable to arrange for all operative work to be done there wherever possible. Because of the time-consuming nature of neurosurgical operations, relatively generous staffing is necessary to provide a satisfactory service' including consultative duties in the region. Many Hospital Centres may urge the appointment of a neurosurgeon to their staff, but it will be impossible to satisfy them all without a wasteful use of manpower and, in most cases, because the full establishment which the work demands cannot be provided. Experience will show if efficiency can be improved by establishing associated centres in the larger regions.
124. The head injury service should be part of the general traumatic service. Some complicated types of head injury are better treated at the neurosurgical centre and should be transferred to it, but :host head injuries do not need to be moved. It is impossible and, what is more, unnecessary that every head injury should have specialist neurosurgical supervision. It is, however, desirable that the general surgeon should have opportunities for acquiring such instruction and experience in the care of head injuries as he may require. Much more attention should be given to the rehabilitation of cases of head injury and closer links should also be forged between the department of neurosurgery and those for rehabilitation and physical medicine.
125. The optimum size of an active surgical unit is about 40 beds. For a population of a million, probably from 75 too 100 beds may be needed for neurosurgeoy and these can be divided between two units.
126. Ancillary Services: It is most important that the services of a pathologist with a sound knowledge of the special methods of neuro-pathology should be available. An anaesthetist with special experience of this work should be attached to every neurosurgical team. The radiological department should provide special assistance, for neuro-radiology needs experience and is time consuming, and the closest collaboration is essential, particularly with neurosurgeoy. Special equipment is also needed. An electro-encephalograph, operated by trained staff, must be available.
127. The service of ophthalmology provided by Regional Boards will ultimately comprise a complete eye service including the provision of spectacles for all who require them This complete service will be impracticable in the early stages in most areas because of lack of trained staff, and provision is made in Part IV of the Act for an interim service, the "Supplementary Ophthalmic Service", which is organised separately from the hospital service. The hospitals now provide facilities of varying degrees of completeness for ophthalmic surgery but only a part of the requirements for refraction and the prescription of spectacles. The problem therefore is twofold: to expand the facilities within the hospitals as may be necessary for a complete ophthalmic surgical service, and to develop the refraction service at hospitals and eye clinics as rapidly as may be to replace the interim service under part IV. Ophthalmologists, ophthalmic opticians and dispensing opticians all have a share in this service and the general lines of development are being examined by a committee of representatives of these groups. A further memorandum will follow on this subject in due course.
128. Hospital beds are required for the ophthalmic surgical service in numbers varying with conditions, particularly with the type of local industry. The number of beds required may be about 20 in a hospital centre serving 100,000 - 120,000 people. In normal circumstances these beds should be -provided in a general hospital. In one or two of the largest Regional Centres it may be appropriate to provide special ophthalmological institutes for postgraduate teaching and research, but the usual arrangement will be a unit of appropriate size in the Teaching Hospital with the rest of the beds required for the centre in one or possibly more hospitals of the Regional Board. The few very small Hospital Centres with populations of the order of 50,000 will require an out-patient service, but it is undesirable that operative work should be undertaken there, because there is insufficient work to permit the specialised training of nursing and resident medical staff.
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